Pre-Screening Campus Entry

Campus Entry Pre-Screening Form

NOTE: For students, this form must be completed by a parent.
From Name
Name (if submitting for a student, please enter student's name): *

First Name Last Name
Email *
example@example.com
Today or within the last 24 hours, have you (or your child, if submitting for a student) experienced any of the following? Check all that apply. *

Feel like you have had a fever? New or worsening cough? Trouble breathing? New loss of sense of taste or sense of smell? New or worsening body aches? Sore throat, different from your seasonal allergies? None of the above
Have you (or your child, if submitting for a student) been exposed to someone who has tested positive or is suspected of having COVID-19 in the past 14 days? *

Yes No
Have you/your student traveled via public transportation (plane or train) in the last 14 days?

Yes No
What is your temperature (Fahrenheit) today? *
While we understand that many of these symptoms can also be related to non-COVID-19 related issues we must proceed with an abundance of caution during this pandemic.

By submitting this form, I certify that the information I have provided is true and accurate and that I/my child is free from the symptoms listed above.

By submitting this form, on my honor I pledge that the information presented here is true to the best of my knowledge.
Please verify that you are human *
Date

Month Day Year
Date Hour Minutes AM/PM Option
Unique Form ID
Please enter the Unique Form ID listed above: *
Should be Empty:

Campus Entry Pre-Screening Form